Medical care
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This article is intended to provide a basic framework for the reader in understanding the structure and products of the information management system that supports the functions of the Veterans Health Administration (VHA). It will identify the primary information resources management organizations in the Department of Veterans Affairs (VA) and briefly describe how they relate to each other; summarize the history, purpose, and contents of the major health care databases; and discuss future directions for VHA's information management efforts.
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Comparative Study
Comparing the use of diagnostic tests in Canadian and US hospitals.
Although Americans pay much more for a day in the hospital than Canadians, we know little about whether inpatient physician practice patterns might explain some of this difference. The authors compared the utilization of all diagnostic imaging (plain radiographs, computed tomography (CT) and magnetic resonance imaging (MRI) scanning, ultrasound, nuclear medicine and vascular studies) and selected laboratory tests (hematology, basic biochemistry, and advanced biochemistry) for all patients discharged with selected medical and surgical diagnoses in 1990 and 1991 from four university hospitals and four community hospitals in Canada (n = 6,491) and the United States (n = 7,980). Overall, US medical patients received 22% more diagnostic tests than their Canadian counterparts (544.2 relative value units [RVUs] vs. 446.5 RVUs in Canada, P < 0.001), which was mainly the result of higher radiology use. ⋯ Comparable inpatients admitted to US hospitals received more diagnostic tests than their Canadian counterparts even in hospitals with similar availability of technology. Differences between countries were larger for high-cost tests than for lower-cost tests. Much of the difference in test use is explained by more intensive use for the elderly in the United States.
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Some physicians caring for critically ill patients have preferences for withdrawing some forms of life support over others, even after the decision to withdraw life support has already been made. Past research has attempted to explain these preferences by variations in clinical circumstances. The authors wondered whether differences in the forms of life support themselves might be important, and whether these differences would reveal implicit goals that physicians attempt to achieve. ⋯ They prefer not to withdraw forms of therapy that require continuous rather than intermittent administration, and forms of therapy that cause pain when withdrawn. Even when a decision has been made to withdraw life-sustaining treatment from a patient, many physicians have preferences for the manner in which this is accomplished. These preferences may reflect perceived intrinsic characteristics of different forms of life support that are consistent across physicians.
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Health-related quality-of-life (HRQOL) measures are becoming increasingly important for evaluating the effectiveness of medical interventions and assessing the health of populations. Preference-based instruments, a subset of HRQOL measures, allow comparisons of overall health status in populations and in clinical settings, and are suitable for economic analyses; but validity studies have used selected samples, mostly examining morbidity. This study compared the performance of a preference-based instrument with self-rated health in predicting subsequent self-rated health, hospitalization, and mortality in a national cohort. ⋯ A preference-based instrument demonstrated predictive validity in three relevant domains of health status outcomes across all sociodemographic groups examined in this cohort. Self-rated health was better able to capture concurrent decrements in health associated with certain chronic illnesses and smoking. It is concluded that preference-based measures capturing both functional status and health perceptions should be incorporated explicitly into national surveys to assess the health of populations.
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To assess the health values of patients infected with human immunodeficiency virus (HIV) and examine the relationships between their health values and health status at two points in time, the authors sought to determine whether patients' physical and mental health statuses were good predictors of how they valued their current state of health. One hundred thirty-nine patients with various stages of HIV infection were interviewed in a prospective cohort study based in a primary care practice of a community-based teaching hospital. Patients were interviewed twice at 6-month intervals using three health value measures--the time trade off, rating scale, and Quality of Well-being Scale--and three health status measures: the 18-item Mental Health Inventory, the Dyspnea-Fatigue Index, and the Medical Outcomes Study SF-36 Health Survey. ⋯ In contrast, health values, particularly time-tradeoff scores, remained stable even in the face of changes in health status and disease progression. With the exception of mental health, the impact of HIV infection on health status tends to parallel the clinical stage of disease. Health values of HIV-infected patients, however, generally are high and correlate better with physical functioning than with mental health.